These guidelines recommend, based on strong evidence, that patients be offered cART as soon as possible after being diagnosed with HIV. People who are newly diagnosed and ready to access treatment immediately should be supported to do so. However, for many people, diagnosis is an emotional shock and they may find it difficult to make an informed decision to initiate cART quickly. It may also take time to address any factors that may affect a patient’s ability to maintain a cART regimen (e.g. willingness, pharmaceutical access, syndemic factors).
Until there is a cure for HIV, antiretroviral therapy is a lifetime commitment, so patients may need support to manage and adhere to therapy throughout the life course.
Although evidence explains when to start therapy, guidelines can help providers and patients implement cART effectively. Optimal care and services delivery can contribute to adherence. Good provider-patient relationships measured across relevant domains (general communication skill and empathy, overall patient satisfaction, willingness to recommend the physician, physician trust, HIV specific communication regarding cART in the context of daily life experiences and skilled adherence dialogue) improve adherence.33, 50, 131 See Appendix C for a the relevant domains and advice on how to means to survey patients. The US DHHS has developed a tool (Table 13) to help providers improve adherence, which identifies barriers to adherence and provides an adherence issues framework. Note: Patients may not always give candid answers in face-to-face surveys. Clinics/practices may consider ACASI (Audio Computer-Assisted Self-Interview Software) or electronic tablet surveys. (See Section 5.0, Promising Practices.)
Effective adherence support techniques – such as phone or electronic reminders and active follow-up contacts, a strong patient-provider relationship that leads to greater understanding of the patient’s circumstances and beliefs, the use of expert conversation skills and reinvigoration of previously delivered messages – can also used be used to retain patients in care (see Section 5.0). Clinics/practices may find it useful to combine retention and adherence efforts. Note: Some strategies, such as reminder systems, may not be effective for patients with complex needs who, for example, may not have phones or access to the Internet. Technology-based or conventional reminders to take medications may be less effective without solid relationships and patient feedback.
Initiation and lifetime commitment
Adherence to cART over the long term
Adherence to cART is essential for patients to achieve and maintain VL suppression, recover CD4 T-cells, avoid drug resistance, improve overall health and survival, and decrease the chance of onward HIV transmission. However, adherence may wane over time and be influenced by age, personal and social factors, number of years since diagnosis, previous therapy, access, substance use and mental state.132, 138 Provider skill and involvement are crucial to retain patients in care and help them achieve high levels of medication adherence.13 Providers should consider nuanced approaches.